By Kate Scannell, MD, Syndicated Columnist
First published in print: 11/02/2014

“The bottom line," she says, "is that I'm dying."

Michele's words are not merely philosophical speculation about our universal human condition. Rather, she speaks from her painfully acute personal circumstances that are shaped by her advanced cancer and her inability to access life-sustaining treatment -- treatment that remains beyond her reach because she is homeless.

Her cancer specialists have recommended a bone-marrow transplant because it's likely to extend her life for months, even years.

"I'd like to have that chance to live longer," Michele says. "But the problem is that I don't qualify for a transplant because I don't have a stable place to live."

In other words, Michele is falling through the cracks of our highfalutin, high-tech health care system for want of a roof. That's because it's routinely required that prospective transplant recipients have a stable place of residence where they can recuperate and receive intensive caregiver support.

Still, what do you do in that predicament if you're homeless -- with no place, literally, to live?

"I keep looking for a rental or subsidized housing," Michele responds, "because I can't afford to give up." But her monthly disability income -- about $970 -- doesn't afford much hope in the Bay Area rental market, where her doctors are located. Still, she spends hours each day searching, all the while struggling with her cancer -- the near-constant bone pain and fatigue it causes, medication side effects, frequent trips to doctors and hospitals and labs.

Ironically, on top of everything, she remains anxious about "getting better" from her most recent disease complication because that might jeopardize her eligibility to remain in the nursing home where she's currently recuperating. It's difficult envisioning returning to the homeless shelter where she previously resided -- not the healthiest environment for an unwell, immunosuppressed woman with terminal illness.

I asked Michele whether she was surprised to find herself in such excruciating circumstances. After all, she'd been working and living independently until January 2011 when, as she recounted, life threw her "a curveball." That's when a bout of severe back pain led to a diagnosis of multiple myeloma within her spine.

"Actually, I'm more confused than surprised," she replied. "I'm confused as to why it's so hard to find housing when you're in such dire need. I don't understand all the obstacles, the endless paperwork, the patchwork social services, why there's no central agency for housing resources to help people with serious illness."

Michele wonders if our culture dismisses the problem, believing a mythology that portrays the homeless as lazy, freeloading, employment-averse people who don’t merit society’s help. And maybe,” she said, “people don’t really understand how easily homelessness can follow when life throws you a curveball like illness – at least not until they are thrown a curveball themselves.”

By weight of statistics alone, you might imagine that public consciousness would be more attuned and responsive to the lived realities of homeless people. For, on any one night in the USA, more than 600,000 people are homeless. And given the higher rates of morbidity and premature mortality within homeless populations, you might imagine that our healthcare system would’ve developed more clever and effective ways to reach homeless persons who are trapped in poverty or circumstances of debilitating illness.

On Oct. 25, a new report in the Lancet threw needed light on these issues. Entitled "The health of homeless people in high-income countries," it reminds us that the causes of homelessness are complex. It posits homelessness as an outcome of dynamic interactions between individual factors (like poverty or health problems) with structural factors that promote homelessness, such as lack of affordable housing or employment opportunities.

I spoke with Dr. Margot Kushel, a professor of medicine at UC San Francisco and an author of the Lancet report. Based in the Division of General Internal Medicine at San Francisco General Hospital, her medical practice and research are highly informed by the lives of many homeless patients.

"We really need to expand our imaginations," she said, "to figure out how to house and provide health care to the homeless." She claimed there existed a compelling moral and an economic case for doing so -- either of which ought to be persuasive.
Kushel offered "the medical respite model" as one successful example of such better-imagined care. At a cost of only about $100 a day, it provides a bed and nursing care for a homeless person needing recovery time after hospitalization for some illness or surgery.

That's remarkably less expensive than prolonged hospital stays, repeated emergency room visits, or hospital readmissions for a medical problem that predictably fails management under conditions of homelessness. Posthospitalization homelessness means no "home" nurse visits or wound care after hospitalization, no home oxygen or IV therapy, no home hospice.

"It's also important we realize that our homeless population is aging," says Kushel. Indeed, the median age of homeless people now approximates 50 years. "And that shift," she emphasizes, "requires our greater attention to their age-related health problems and chronic diseases, as well as to frailty and geriatric issues."

At the moment, however, there's no comprehensive safety net for Michele. Deanie Hubbell, who works with Michele as a volunteer at Oakland's Women's Cancer Resource Center, reminds us: "Going through a cancer diagnosis and treatment course is challenging in the best of circumstances. But for those who are homeless, without a support network or resources, it can be deadly."
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Kate Scannell is a Bay Area physician who encourages support of the Women's Cancer Resource Center in Oakland. Go to www.wcrc.org/ or call 510-601-4040.
Copyright 2014, Kate Scannell

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